Basic Information
| Provider Information | |||||||||
| NPI: | 1437404068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TERRA | ||||||||
| FirstName: | EVELYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15574 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LATHROP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953309725 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8626 LOWER SACRAMENTO RD | ||||||||
| Address2: | SUITE 41 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952101835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094782487 | ||||||||
| FaxNumber: | 2094781476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 07/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.